Chris Willott

Listening to the rumours: What the northern Nigeria polio vaccine boycott can tell us ten years on

In 2003 five northern Nigerian states boycotted the oral polio vaccine due to fears that it was unsafe. Though the international responses have been scrutinised in the literature, this paper argues that lessons still need to be learnt from the boycott: that the origins and continuation of the boycott were due to specific local factors. We focus mainly on Kano state, which initiated the boycotts and continued to reject immunisations for the longest period, to provide a focused analysis of the internal dynamics and complex multifaceted causes of the boycott. We argue that the delay in resolving the year-long boycott was largely due to the spread of rumours at local levels, which were intensified by the outspoken involvement of high-profile individuals whose views were misunderstood or underestimated. We use sociological concepts to analyse why these men gained influence amongst northern Nigerian communities. This study has implications on contemporary policy: refusals still challenge the Global Polio Eradication Initiative; and polio remains endemic to Nigeria (Nigeria accounted for over half of global cases in 2012). This paper sheds light on how this problem may be tackled with the ultimate aim of vaccinating more children and eradicating polio.

Conceptualising global health: theoretical issues and their relevance for teaching

BackgroundThere has long been debate around the definition of the field of education, research and practice known as global health. In this article we step back from attempts at definition and instead ask what current definitions tell us about the evolution of the field, identifying gaps and points of debate and using these to inform discussions of how global health might be taught.DiscussionWhat we now know as global health has its roots in the late 19th century, in the largely colonial, biomedical pursuit of ‘international health’. The twentieth century saw a change in emphasis of the field towards a much broader conceptualisation of global health, encompassing broader social determinants of health and a truly global focus. The disciplinary focus has broadened greatly to include economics, anthropology and political science, among others. There have been a number of attempts to define the new field of global health. We suggest there are three central areas of contention: what the object of knowledge of global health is, the types of knowledge to be used and around the purpose of knowledge in the field of global health. We draw a number of conclusions from this discussion. First, that definitions should pay attention to differences as well as commonalities in different parts of the world, and that the definitions of global health themselves depend to some extent on the position of the definer. Second, global health’s core strength lies in its interdisciplinary character, in particular the incorporation of approaches from outside biomedicine. This approach recognises that political, social and economic factors are central causes of ill health. Last, we argue that definition should avoid inclusion of values. In particular we argue that equity, a key element of many definitions of global health, is a value-laden concept and carries with it significant ideological baggage. As such, its widespread inclusion in the definitions of global health is inappropriate as it suggests that only people sharing these values may be seen as ‘doing’ global health. Nevertheless, discussion of values should be a key part of global health education.SummaryOur discussions lead us to emphasise the importance of an approach to teaching global health that is flexible, interdisciplinary and acknowledges the different interpretations and values of those practising and teaching the field.

The evolution of global health teaching in undergraduate medical curricula.

BackgroundSince the early 1990s there has been a burgeoning interest in global health teaching in undergraduate medical curricula. In this article we trace the evolution of this teaching and present recommendations for how the discipline might develop in future years.DiscussionUndergraduate global health teaching has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalization, cross-border movement of pathogens and international migration of health care workers. This teaching has many different strands and types in terms of topic focus, disciplinary background, the point in medical studies in which it is taught and whether it is compulsory or optional.We carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that this teaching is rising in prominence, particularly through global health elective/exchange programmes and increasing teaching of subjects such as globalization and health and international comparison of health systems. Our findings indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance.We suggest that there are three types of doctor who may wish to work in global health – the ‘globalised doctor’, ‘humanitarian doctor’ and ‘policy doctor’ – and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special overseas doctor track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study.SummaryWe argue that teaching of global health in undergraduate medical curricula must respond to changing understandings of the term global health. In particular it must be taught from the perspective of more disciplines than just biomedicine, in order to reflect the social, political and economic causes of ill health. In this way global health can provide valuable training for all doctors, whether they choose to remain in their countries of origin or work abroad.

Introducing medical students to global health issues: a Bachelor of Science degree in international health

Many people have struggled to produce a definition forthe term globalisation. A huge debate has also taken placeas to the relative advantages and hazards caused by theincreased flow of goods, people, and informationbetween nations, and their effects on health. One of theclear examples of gain is the growing interest by medicalstudents around the world in issues affecting health andhealth care, not only in their own nations, but also acrossthe world.

Doctors as the governing body of the Kurdish health system: exploring upward and downward accountability among physicians and its influence on the adoption of coping behaviours

BackgroundThe health system of Iraqi Kurdistan is severely understudied, particularly with regard to patient-physician interactions and their effects. We examine patterns of behaviour among physicians in Kurdistan, the justifications given and possible enabling factors, with a view to understanding accountability both from above and below.MethodsAn ethnographic study was conducted in the Sulaimaniyah Teaching Hospital in the Kurdistan Region of Iraq. Data was collected through negotiated interactive observation, and interviews were conducted with 10 participants, 5 physicians and 5 patients. Data collected was analysed using thematic analysis.ResultsCommon patterns of practice among physicians in Kurdistan include displays of discontent, reluctance to negotiate decisions with patients and unfavourable behaviours including dual practice and predatory behaviours towards patients. These behaviours are justified as a mechanism of dealing with negative aspects of their work, including overcrowding, low salaries and social pressure to live up to socially conceived ideas of a physician’s identity.ConclusionsMichael Lipsky’s theory of street-level bureaucrats and their coping behaviours is a useful way to analyse the Kurdish health system. Physician behaviours are enabled by a number of factors that work to enhance physician discretion through lowering of upward and downward accountability. Physicians are under very little pressure to change their behaviour, and as a result, they effectively become the street-level governing body of the Kurdish health system.

Rejecting Continuity and Rupture Arguments for Historical Syncretism in Understanding Bureaucracy in Contemporary South-Eastern Nigeria

Patronage and financial corruption are rife in the contemporary Nigerian state and have gained widespread social acceptance, indicating a belief that it is legitimate to appropriate state resources for personal gain. In this paper I concentrate on the historical antecedents of this state of affairs. Focusing on the Igbo-speaking south-east of the country, I argue that an understanding of contemporary Nigeria must be based on a syncretic analysis: that is, a combination of influences from pre-colonial, colonial and post-colonial eras. Despite this, the colonial era should not be downplayed as an influence, as some have sought to argue. In particular, I argue that the imposition of warrant chiefs in previously acephalous communities with participatory governance engendered a belief that government did not belong to local people.